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To enhance the effectiveness of smoking cessation communication in primary care by gaining insight into the motivations and perceptions of smokers and ex-smokers with chronic obstructive pulmonary disease (COPD).
Stopping smoking is the single most important action smokers with COPD can take to improve their health. A Cochrane systematic review identified the need for more research into effective smoking cessation approaches for patients with COPD.
A qualitative study using semi-structured interviews with COPD patients in South Yorkshire undertaken as part of the formal evaluation of an innovative rehabilitation program (‘Breathing Space’).
Patients with COPD (current and ex-smokers) who were invited to attend a program of rehabilitation or support at Breathing Space
Current smokers tended to deny the contribution of smoking to their COPD. A low level of acknowledgement of the association between smoking and COPD was demonstrated, particularly by long-term COPD patients. Participants described health and money as the most important motivators in stopping smoking. An overly directive or ritualistic approach by health professionals was perceived as counter-productive. Participants perceived that smokers were deterred from accessing care through embarrassment and fear of discrimination.
A direct but supportive approach is likely to be effective when discussing the association between smoking and COPD with patients. Assisting smokers to acknowledge the objective dangers and the personal risk of smoking is indicated. Approaching smoking as an objective condition to be solved as a joint enterprise between patient and clinician can reduce message avoidance while inducing a sense of personal control, thereby increasing successful quitting.
We describe here an innovative scheme in general practice that provides a work-base environment for student counsellors with funding for counselling supervision and co-ordination.
The reported mental health prevalence rate in the UK among the general population is 23%. Only 76% of the above population visit a general practitioner, and of these only 44% will be diagnosed. Patients that present depressive symptoms, for example, are not always identified, and yet there is an increased recognition of the need for early diagnosis. There is little or no National Health Service (NHS) funding for counselling services in many areas of England. The training received by general practice registrars, to appropriately assess mental health problems within a typical consultation, has been the focus of a long-standing debate.
This study outlines the proposed counselling model and presents some preliminary feedback on the patient outcomes achieved.
Results and Conclusion
The provision of a training environment for counsellor students is an option for increasing access of patients to counselling under the NHS.
This study investigated two initiatives for preventing falls in Cheshire: public events to raise population awareness about falls and ways of preventing falls, a programme of falls assessments and falls prevention classes.
The study aimed to support service development by generating local learning about: the falls risk status of older people attending the public events and their use of services for preventing falls, the efficiency and effectiveness of the falls programme.
A local adaptation of an instrument used in similar research was administered to assess the falls risk status of older people attending the public events. This instrument captures data about the age, sex, gait, sensory deficit, falls history, current medication, medical history, mobility and living situation of respondents. Attendees were also asked about their current use of falls services. To evaluate the falls programme data were collected about the characteristics and referral sources of service users and, for users of the falls prevention classes: their mobility and balance on joining and completing the classes; their fear of falling and confidence linked to falls at the start of the classes and six months later; the number of falls they experienced in the six months before starting and after completing the classes.
Of the 453 attendees screened, 64.3% were at medium risk of falling or above and 34.3% had suffered previous falls. None were accessing falls prevention services. During its first year, 324 individuals were referred to the falls programme. Overall, among those individuals who provided data for analysis, there was a statistically significant improvement in the ‘clinical’ outcomes assessed and a statistically significant reduction in the occurrence of falls. The majority of respondents indicated that they achieved an improved confidence linked to falls and a reduced fear of falling.
Studies of this type can provide a valuable contribution to local learning but the characteristics of the research collaborations developed can affect study designs and the quality of the information generated. Improved contracting arrangements between service commissioners and providers may provide an opportunity to increase the rigour of local developmental studies.
The aim of this study was to evaluate the implementation phase of a multidisciplinary persistent pain service (PPS).
A multidisciplinary PPS was established in January 2008 at the London Borough of Tower Hamlets. Referral is made into the service via general practitioners (GPs). Patients see an appropriate mix of clinicians; they include a pain specialist, physiotherapists, an occupational therapist, psychologists and/or health and advice worker.
Data were collected by using patient questionnaires, monthly activity reports from clinicians, service administration and patient and staff interviews.
Service activity steadily increased to full capacity after nine months. Eighty-two percent (31/38) of Tower Hamlets GP clinics referred patients to the service; the referrals were appropriate. The discharge rate at nine months was 5% while 9% failed to attend or declined to attend. Patients saw on average two clinical specialities, post multidisciplinary team discussion and had four appointments. The majority of patients were female (89/144, 62%); between 41 and 60 years old (55%), unemployed (79%), received disability or incapacity allowances (28%), had pain for more than 10 years (27%) and were not fluent in English (37%). The patient and practitioner interviews highlighted: difficulties keeping track of patients as they progressed through the service, inconsistent administration that affected patient satisfaction, lack of understanding of treatment process and plans and cross discipline learning benefit for staff.
Implementing a multidisciplinary service requires forethought, and regular monitoring to ensure efficiency. For multidisciplinary services we recommend: GP education, clear delineation of responsibilities between staff, efficient systems for tracking patient progress, regular staff meetings and jointly negotiated treatment plans that patients can keep.
To explore changes in self-reported familiarity and use of guidelines dealing with cardiovascular risks (hypertension, dyslipidemia, adult obesity and smoking cessation) and general attitudes towards clinical guidelines before and after implementation programme, as well as the association of guideline training attendance and attitudes towards and use of guidelines.
The current care guidelines provide a useful tool in the management of cardiovascular risk factors. Evidence-based care and guideline use have a shorter tradition among nurses than among physicians.
A self-administered questionnaire was sent to all primary health care nurses and physicians in Päijät-Häme Health and Social Care District, an area of 210 000 inhabitants in Southern Finland, before and after the guideline implementation programme VALTIT.
Main outcome measures were self-reported familiarity with and use of guidelines on cardiovascular risks and items measuring attitudes towards clinical guidelines.
Among nurses, the reported familiarity with all the guidelines increased, but increase in use occurred only in respect of the dyslipidemia guideline. Among nurses, there was an association between participation in guideline training and guideline use. Physicians’ reported familiarity with and use of the adult obesity guideline increased during the study period. The proportion of nurses and physicians who reported that they had been asked to use the guidelines increased. Perceptions concerning the readiness to adopt the guidelines changed positively among nurses and were more positive among those attending at least one training event.
Results are encouraging regarding familiarity with guidelines. Regarding usage our results suggest that a two-year programme might not be enough to alter the deep-rooted practices and attitudes concerning lifestyle change related guidelines. The challenge lies in multi-professional implementation of guidelines on cardiovascular risks with special emphasis on lifestyle change as a treatment option.
To explore the views and experiences of obese patients prescribed anti-obesity drugs in primary care, including their understanding of guidance about lifestyle changes.
Pharmacotherapy treatments are increasingly used to support obesity management. Currently, two anti-obesity drugs are available on the National Health Service (NHS): Orlistat and Sibutramine. Although detailed clinical guidelines for their use are well documented, there is little research about how obese individuals experience and view these drugs in routine care.
Qualitative design with semi-structured interviews conducted in participants’ homes or a health centre. Participants recruited from three general practices in Sheffield with socio-economically diverse populations using purposive sampling. Interviews transcribed verbatim and analysed using the ‘framework’ approach.
Health concerns are the key factor for patients seeking help with weight loss. Participants are typically ambivalent about taking anti-obesity drugs and expectations vary from unreasonably sceptical to unreasonably optimistic. There appears to be high awareness of the need for lifestyle change. Those prescribed Orlistat understood how it worked, however, those on Sibutramine and Rimonabant did not. Participants’ experiences in taking anti-obesity drugs varied greatly and changed with experiences of weight loss, side effects and quality of support. Most could identify points at which the information, choice and support provided by primary care could be improved. However, most were not aware of other avenues of support.
This study has identified a number of areas for service improvement. Better understanding of patient expectations around anti-obesity drugs should help the NHS to shape services to meet needs and make the experiences of patients more positive.
The aim of this study was to describe how healthcare professionals experience and perceive the use of interpreters in their contacts with patients with whom they do not share a common language.
Language barriers lead to poor-quality care and fewer medical contacts. To avoid language barriers and their consequences, interpreters are recommended. However, communicating through an interpreter can be difficult. To develop effective interpreter service it is important to study healthcare staff’s perceptions of using an interpreter.
An explorative descriptive study design was used. The study was conducted in different healthcare settings in Sweden and included 24 healthcare staff, of whom 11 were physicians, 9 nurses, 2 physiotherapists and 2 assistant nurses. Data were generated through written descriptions of the use of interpreters in healthcare service and were analysed using qualitative content analysis.
Two main categories emerged from the data: 1) aspects related to the interpreter and 2) organizational aspects. The study showed that having a face-to-face, professional, trained interpreter, with a good knowledge of both languages and of medical terminology, translating literally and objectively, was perceived positively. The organizational aspects that affected the perception were functioning or non-functioning technical equipment, calm in the interpretation environment, documentation of the patients’ language ability, respect for the appointed time, and the level of availability and service provided by the interpreter agency. It is important to develop a well-functioning interpreter organization that offers trained interpreters with a professional attitude to improve and ensure cost-effective and high-quality encounters and care.
There is widespread, unexplained variation in activity and outcome between general practices.
To explore the relationship between practice size and participation in optional activities, including the Quality and Outcomes Framework (QOF).
Design of study
Cross-sectional analyses of routinely available data on practice characteristics, QOF performance and optional activities including undergraduate teaching, postgraduate training, research, enhanced clinical data collection and service development.
All 1031 general practices were located in mainland Scotland.
The most popular optional activity was undergraduate medical teaching, which involved 41% of all general practices. About a third of practices took part in postgraduate general practitioner training (29%), research (33%), enhanced clinical data collection through the Scottish Programme for Improving Clinical Effectiveness (31%) and the activities of the Scottish Primary Care Collaborative (33%). The most important driver of the number of activities undertaken by a practice is size with single handed, small and medium sized practices all undertaking a significantly lower number of activities than larger practices (P < 0.001). Deprivation had no overall effect, but was associated with lower rates of participation in postgraduate training. The average number of points achieved in the QOF ranged from 961 by the 18% of practices taking part in no optional activities, to 973 by 29% of practices taking part in one activity, 984 by 25% of practices taking part in two activities and 985 in 28% of practices taking part in three or more activities. Single handed practices in urban areas taking part in three or more additional activities had similar QOF point totals to larger practices taking part in three or more activities, and achieved 44 more QOF points than urban single-handed practices taking part in less than two additional activities.
Practice size is strongly related to participation in optional activities. There is a small but significant relationship between the practice size and number of QOF points achieved by practices taking part in less than two additional activities. Participation in optional activities is a possible indicator of cultural and organisational factors within practices, which constrain the volume and quality of services, which they are able to provide.
This study assessed the prescription of potentially nephrotoxic non-steroidal anti-inflammatory drugs (NSAIDs) to patients with chronic kidney disease (CKD) in general practice.
CKD poses a considerable disease burden in the UK. Guidelines state that caution should be exercised when prescribing NSAIDs to CKD patients, due to increased risk of rapid kidney disease progression.
We reviewed the medical records of 1427 patients with CKD Stages 3–5 in seven general practices in West Yorkshire.
A total of 792 (55.5%) were prescribed NSAIDs; 128 (9%) of these were prescribed NSAIDs excluding low-dose aspirin. Twenty-three (20.2%) patients who were prescribed NSAIDs had no record of CKD monitoring in the preceding year.
Prescription of NSAIDs is likely to be contributing to unnecessary renal impairment.